These included failures in diagnoses and treatment, inappropriate discharge and aftercare, poor risk assessment and safety practices, lack of dignity and rights infringement, and poor communication.

For example, the ombudsman cited one case where a woman was treated with anti-psychotic drugs but had a life-threatening reaction to them, but her physical symptoms were dismissed and she died.

“There is a growing gap between demand for services and the level of funding and staff needed to deliver them”

Saffron Cordery

In another case, a man with a complex history of mental health problems died from a drug overdose after being discharged from the local community mental health service without a care plan.

The report highlighted a further example where a patient with bipolar disorder and autism was assaulted by another resident in a home, which could have been prevented by a risk assessment.

In addition, it noted a woman suffering from a psychotic episode was not given sanitary products while she was menstruating and was forced to use a plastic cup, while another woman with bipolar disorder had her new born baby taken from her unnecessarily and without explanation.

Rob Behrens

Rob Behrens

Rob Behrens, parliamentary and health service ombudsman, said: “This report shows the harrowing impact that failings in mental healthcare can have on patients and their families.

“Too many patients are not being treated with the dignity and respect they deserve and this is further compounded by poor complaint handling,” he said.

The ombudsman said the findings provided fresh impetus to deliver recommendations in NHS England’s Five Year Forward View for Mental Health and reinforced conclusions made by the Care Quality Commission last year.

Brian Dow, director of external affairs at Rethink Mental Illness, said the report reflected what patients had been telling the charity about “overstretched services”.

“These findings underline the desperate need for reform and the sometimes devastating consequences of a struggling system,” he said.

“It is evident that there is a growing gap between demand for mental health services and the level of funding and staff needed to deliver them,” she said.

“Every patient deserves to be treated with dignity and respect, and feel confident in raising issues with their care should they need to,” she said.

“As the number of mental health nurses continues to fall, they must be given the support and tools they need to deliver high-quality care for all,” said Ms Cordery.

She added: “Funding commitments for mental health services must be met with action, and must reach the front line to improve the experience for patients.”

Sean Duggan

Sean Duggan, chief executive of the Mental Health Network, which is part of the NHS Confederation, highlighted that “many positive steps” were already being taken to improve patients’ experience.

“It is never easy to hear of serious failings in patient care, but it must be recognised that many of the report’s findings pre-date the Five Year Forward View for Mental Health – meaning action is already being taken,” he said.

He added that the findings showed why initiatives like the Children and Young People’s green paper and the independent review of the Mental Health Act were “so vital and so timely”.

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Readers' comments (2)

Always the negative, I've just done 6 night shifts on a psychiatric intensive care unit, being verbally abused by a patient, had patients make racist and hurtful comments to staff trying to do their upmost best, do I still come to work cheerful and compassionate, always. But thanks for appreciating the mental health nurses who do their best....

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